Real-world assessment of clinical outcomes of first-line treatment in metastatic papillary Renal Cell Carcinoma

Abstract Background Papillary renal cell carcinoma (pRCC) is the most common non-clear cell RCC (nccRCC), representing up to 15% of RCC cases. Phase 2 trials have evaluated first-line (1 L) immunotherapy (IO)-based treatment in nccRCC, but with heterogeneous cohorts and limited comparative data. The specific value of IO for metastatic pRCC (mpRCC) remains unquantified. Methods We analyzed prospectively collected data from the Canadian Kidney Cancer Information System (CKCis) to assess the efficacy of 1 L systemic therapy in mpRCC with IO-based regimens versus tyrosine kinase inhibitors (TKI). The primary endpoint was time-to-treatment failure (TTF). Secondary endpoints included overall survival (OS), objective response rate (ORR), and treatment-related adverse events (TRAEs). Analyses were adjusted (adj) for IMDC risk groups. Results From 2011 to 2024, 197 mpRCC patients received 1 L therapy: 70 with IO (alone or in combination) and 127 with TKI. Median follow-up was 21.6 months. Median TTF was 9.9 months with IO vs 5.9 months with TKI (adjHR: 0.62 0.43-0.91 p = 0.01). Median OS was 36.9 months with IO vs 23.2 months with TKI (adjHR: 0.54 0.3-0.9, p = 0.018). ORR was 37% with IO vs 23% with TKI (adjOR: 2.2 0.95-5.2 p = 0.07). The TKI-IO subgroup showed the longest TTF (16.9 months, adjHR: 0.47 0.26–0.85, p = 0.01) and OS (not reached, adjHR: 0.26 0.08–0.83, p = 0.02), compared to TKI. Grade 3–5 TRAEs occurred in 31% (IO) vs. 27% (TKI). Conclusion This real-world study highlights the benefit of IO-based treatment in mpRCC, particularly in the TKI-IO subgroup. Our findings may inform further trials evaluating 1 L IO in mpRCC.